About the service:

Grace Lodge is a care home providing personal care for up to 65 older people. The home is purpose built and the accommodation is over two floors. At the time of the inspection there were 56 people living at the home.

People’s experience of using this service:

Before this inspection we received some complaints and negative feedback from relatives of people who wanted to share their experiences of Grace Lodge with us. We found during this inspection that some improvements were required to records and auditing systems.

Care plans were not always kept up to date and some information regarding wound care and management of wound care was confusing. Auditing was being completed, and actions were drawn up, however, there was only a small sample of audits taking place every month. We have made a recommendation concerning this. We received mixed feedback in relation to staffing levels, staff training and management support. We raised this feedback with the registered provider during our inspection, and they have rectified some of the issues we found and have a plan in place to address the rest. They have agreed to keep us updated with the progress of this.

People we spoke with and their relatives said they felt safe living at Grace Lodge. Checks and routine management were completed, and staff were recruited safely. There was a process for documenting incidents and accidents, and staff understood their role with regards to safeguarding. Risk assessments were in place, however, some risk assessments required reviewing, which we raised at the time with registered provider.

The registered manager was working within the principles of the Mental Capacity Act 2005, and associated legislation. Deprivation of Liberty requests continued to be monitored by the registered manager. People were supported with their eating and drinking needs, we sampled the food and found it tasted nice. The menu was displayed in the dining room, however, there was no consideration to presenting the menu in alternative formats to support people’s understanding. We raised this with the registered provider who said they would implement this. We saw, in the most part, referrals were being made when needed to external health care professionals. Staff were supervised regularly.

We observed kind and caring interactions between staff and people who lived at the home. People were complimentary regarding the staff. Care plans contained dignified and respectful information which supported people’s diverse needs.

Complaints were documented and responded to in line with the registered providers complaints policy. People were supported with end of life care needs, and the registered provider discussed with us how they were developing further training in this area. There was some mixed feedback with regards to the activities. Activities took place, but some people and their relatives felt this could be improved.

People and their relatives knew who the registered manager was. Staff team meetings took place, and people were asked to submit feedback regarding the home and their experience of Grace Lodge using a feedback form. Some of the actions from the last feedback had been implemented. The registered manager had reported all events that affected the service to CQC in line with regulatory requirements. The registered provider was already making changes to service provision and systems to improve.

Rating at last inspection: rated good report published January 2017.

The service is now rated ‘Requires Improvement’ overall.

Why we inspected: We brought the date of this inspection forward due to information we received of potential risk and concern.

Follow up: ongoing monitoring; We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC websit

Grace Lodge is a purpose built home which provides accommodation for up to 65 people who require nursing or personal care. The home is built on two levels with a passenger lift and staircases available for access to the first floor. There are 59 single and three companion bedrooms, each with en-suite facilities. All the rooms are connected to a nurse call system. The home has a rear garden for residents’ use.

This was an unannounced inspection which took place on 15 and 16 December 2016.

The service was last inspected in July 2015 and at that time was found to be in breach of two of the regulations under the Health and Social Care Act 2008 (HSCA). The breach of regulations was due to concerns with the safe management of medicines and the application of the Mental Capacity Act 2005 for people who may lack capacity to consent to their care and treatment. The service had been rated as ‘Requires improvement’.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the HSCA and associated regulations about how the service is run.

At this inspection we found the home to be meeting all of the regulatory requirements.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 [MCA] were followed, in that an assessment of the person’s mental capacity was made and decisions made in the person’s best interest. We had some discussion, however, how this could be further improved by evidencing assessment around individual decisions; this would meet best practice and follow the principles of the MCA.

The registered manager had made appropriate referrals to the local authority applying for authorisations to support people who may be deprived of their liberty under the Deprivation of Liberty Safeguards (DoLS). DoLS is part of the MCA and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. We found the applications were continuing to be monitored by the registered manager.

We were given very positive feedback from the people we spoke with who were living at Grace Lodge. They told us they enjoyed living at the home and they were well cared for.

We reviewed the way people’s medication was managed. We saw there were systems in place to monitor medication so that people received their medicines safely.

There were enough staff on duty to help ensure people’s care needs were consistently met.

We looked at how staff were recruited and the processes to ensure staff were suitable to work with vulnerable people. We found recruitment to be well managed and thorough.

The registered manager was able to evidence a series of quality assurance processes and audits carried out internally and externally by staff and from visiting senior managers for the provider. These were effective in managing the home and were based on getting feedback from the people living there.

Care was organised so any risks were assessed and plans put in place to maximise people’s independence whilst help ensure people’s safety.

The staff we spoke with described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. Training records confirmed staff had undertaken safeguarding training and this was on-going. All of the staff we spoke with were clear about the need to report any concerns they had.

Arrangements were in place for checking the environment to ensure it was safe. For example, health and safety audits were completed where obvious hazards were identified. We found the environment safe and well maintained.

Activities were organised in the home and these were appreciated by the

We did not announce our inspection prior to our visit. We set out to answer our five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people who lived at the home, their relatives and staff and by looking at records. We spoke with 16 of the people who lived at the home, seven relatives and eight members of staff. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

People who lived at the home told us they were treated with respect and dignity by staff. People told us they felt safe and that if they had any concerns they would raise these with staff or with the manager.

People’s health, safety and welfare were protected in how the service was provided. People got the support they needed and risks to people’s safety were assessed and managed.

Accidents and incidents were being recorded appropriately and action was taken in response to these.

The provider had systems in place to monitor staff practices and to ensure risks to people’s health and wellbeing were managed.

People’s capacity to make decisions had been assessed and the manager was aware of their responsibility, in line with the Mental Health Act 2005, to refer to external professionals if it was felt that a person was being deprived of their liberty.

Is the service effective?

People’s needs were assessed prior to them moving into the home. Care was then planned and delivered in line with people’s assessed needs.

People received the care and support they required to meet their needs and maintain their health and welfare. Checks were in place to monitor and review the care that people received to make sure people received the right care and support that met their needs.

Is the service caring?

People who lived at the home told us staff were caring and respectful. People’s comments included: “The carers are very good” and “They have patience and just do the job calmly with kindness and thoughtfulness.”

Staff told us they were clear about their roles and responsibilities to promote people’s independence and respect their privacy and dignity. We saw that staff were respectful and warm in their interactions with people.

Is the service responsive?

The service worked well with other agencies to make sure people received the care and treatment they needed. GPs and other health professionals were referred to promptly when people required support with their health care needs.

We spoke with a visiting health professional and they gave us good feedback about the home and told us staff carried out their instructions appropriately.

We found there were few activities for people who lived at the home to take part in. There were no designated staff to support people with activities and care staff told us they were too busy supporting people with their care needs to also provide support with activities.

We found there were only two permanent qualified nurses working at the home at the time of our inspection and one of these was the Registered Manager. There were five vacant posts for qualified nurses and the vacancies were being covered by the manager, the deputy manager and a high use of agency staff. As a result we judged the provider did not have sufficient numbers of suitably qualified, skilled and experienced persons employed at the home. A compliance action has been set for this and the provider must tell us how they plan to improve.

Is the service well-led?

Systems were in place for assessing and monitoring the quality of the service. These included regular checks on areas of practice such as care planning, wound management, infection control, management of falls, fire safety, staff supervision and training.

People who lived at the home and their relatives were also surveyed about the quality of the service and their feedback was acted on.

The manager ensured staff received up to date training. Staff told us they felt well supported and we saw that they were receiving regular supervision and appraisals.

We found people's care plans and associated records included all the information staff needed to ensure people received the right care and support. Risk management plans which were in place and kept up to date ensure people were cared for and supported safely.

We found that people's records had been reorganised making it easier to find relevant information essential to their care and welfare. Records had been regularly reviewed and were up to date.

We spoke with six people who used the service and five of their relatives. They told us that the care they had received had been delivered in a way that respected people’s privacy and dignity and their individual wishes. Their comments included,

"I can’t fault them.”

“They don't rush you."

“I feel safe and contented here.”

“The staff will do anything for you.”

“We have no complaints at all.”

“There is a choice of food.”

“They communicate with us.”

” All the staff are really lovely.”

The scheduled inspection was brought forward due to concerns raised about Grace Lodge Nursing home in regards to an increase in safeguarding referrals and concerns raised about the care of people living in the home.

During our inspection we found evidence that care records for the people who used the service were not all up to date and did not contain enough information or relevant risk assessments for people to be cared for safely and effectively.

People who we spoke with told us that they felt safe and had no concerns about the care they had received from staff. We saw that appropriate safeguarding records were kept and reported on. We found that relevant employment checks were made on staff working in the home.

We met a number of residents during our visit and observed people going about their days.

There was a singer performing and a number of residents were watching this and clearly enjoying the show. One resident said, ‘’I like it when there’s a ‘turn’ on, we have a fair few.’’

We saw carers spending time with residents in communal areas, and also chatting with those residents who had chosen to stay in their rooms. We chatted with a resident who generally, preferred to stay in her room and she told us, ‘’I like my own company, but they (the carers) do pop in and see me and it’s nice to see their faces.’’

We spoke with a number of residents as well as two visiting relatives, during our visit. We received some very positive feedback. Comments included:

‘’The staff here are brilliant. Nothing ever seems to be too much trouble.’’

‘’It’s lovely here, they are all very good to me.’’

‘’I can come and go as I please. I go out a lot!’’

‘’I don’t ever mind visiting here. They are all very welcoming and you don’t feel like you shouldn't be here.’’

‘’They seem to look after people here very well. I’ve never seen anything to make me worried.''

We looked at a number of areas during the inspection, which included how the home promoted the care and welfare of people using the service and how they safeguarded the rights of people who were not able to consent to treatment. We found that the service was compliant in all the areas we assessed.

This unannounced inspection of Grace Lodge Nursing Home took place over two days on 22 and 23 July 2015.

Grace Lodge Nursing Home is a care home that provides accommodation, nursing care and treatment for up to 65 adults who have nursing care needs. Accommodation is provided over two floors and the home is accessible to people who are physically disabled. Access to the upper floor is via a staircase or passenger lift. The service is situated in the Walton area of Liverpool. It is in close proximity to local shops, other local amenities and public transport links.

We carried out this inspection to follow up on requirements set at the last inspection. Following the last inspection in March 2015 we told the provider to take action to make improvements to the service in the following areas: the arrangements to protect people from abuse, the management of medicines, the cleanliness of the home, staffing levels, how staff were supported in their role, care planning, the quality of food and meals, the handling of complaints and how they checked on the quality of the service.

Since our last inspection of the service the company registered to provide the service has been taken over. As a result a new registered person and management team were in place. The provider sent us a detailed action plan following the inspection outlining what action they were going to take to make the required improvements. At this inspection we found improvements had been made in all of the areas. Some of the improvements were still embedding but overall the service was safer, more effective, more responsive and better led than we had found at our last inspection. The provider had introduced new ways of checking on the quality of the service and was listening to people’s views about the service and acting on them. A new management team were in place to support the developments in the service.

There was a registered manager at the service at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found that people living at the home were protected from avoidable harm and potential abuse because the provider had taken steps to minimise the risk of abuse. Procedures for preventing abuse and for responding to allegations of abuse were in place. Staff told us they were confident about recognising and reporting suspected abuse and the manager was aware of their responsibilities to report abuse to relevant agencies.

Each of the people who lived at the home had a plan of care. Overall, these provided a sufficient level of information and guidance on how to meet people’s needs. Risks to people’s safety and welfare had been assessed as part of their care plan. Guidance on how to manage identified risks was included in the information about how to support people. People’s care plans included information about their preferences and choices and about how they wanted their care and support to be provided.

Staff worked well with health and social care professionals to make sure people received the care and support they needed. Staff referred to outside professionals promptly for advice and support.

Medication was in good supply and was stored safely and securely. We found that improvements had been made to how medicines were managed but we found some areas where further improvements were required. You can see what action we have told the provider to take at the end of the report.

The manager told us they and senior members of staff had been provided with training on the Mental capacity Act (2005). However, we found there was no consistency in how the principles of the act were applied in practice. You can see what action we told the provider to take at the end of the report.

People who lived at the home and visiting relatives gave us good feedback about the staff team and their skills in supporting people.

People told us they enjoyed the meals and food provided. The majority of people we spoke with told us the quality and quantity of food was good. People were provided with drinks on a regular basis during the course of our visit.

Staffing levels were sufficient to meet the needs of the people living at the home at the time of our inspection. However, there were only 49 people residing at the home as a result of the provider undertaking a voluntary agreement to not admit any new people following the findings of our last inspection. The provider has given us assurances that they will regularly review staffing levels as the number of people living at the home increases.

Staff told us they felt supported in their roles and responsibilities. Staff had been provided with relevant training, team meetings had been taking place and staff supervision meetings had commenced since our last visit to the service. New procedures had been introduced to support staff in their roles and to promote good communication and accountability across the service.

The home was accessible and aids and adaptations were in place to meet people’s needs and promote their independence. The premises were well maintained and a programme of refurbishment had commenced. The home was clean and people were protected from the risk of cross infection because staff had been trained appropriately and followed good practice guidelines for the control of infection.

The provider had introduced new systems to check on the quality of the service and to ensure people who lived at the home were listened to and their views acted upon. The provider had taken action to address the concerns from our previous inspection and we found significant improvements had been made to the service. Some of these require time to embed into practice and the provider now needs to demonstrate continued improvement and sustainability of the improvements made.